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Phantom limb pain and brachial plexopathy

These conditions are caused by severe trauma to tissues and nerves and will usually be given high priority by PPMS, therefore clearly state in the referral if these conditions are present. Referral in the early phase is desirable.

Referral requirements

A referral may be rejected without the following information.

Essential referral information

  • Persistent Pain Management Service eReferral form
  • Reason for referral
    • Management plan
    • Specific concerns re medication overuse/dependence
    • Specific interventions
    • Need for a multidisciplinary approach
  • History of condition
    • Date of onset (duration of condition)
    • Mechanism of injury
  • Current and previous relevant medical conditions
  • Management of condition including treatments trialled and reasons for failure
    • Include relevant specialist letters
  • Any forensic or current medicolegal issues
  • Current medications and past drugs used for pain
  • Allergies
  • List drug dependencies, inappropriate drug use and prescribed drug misuse e.g. nicotine, alcohol, cannabis, opioids
  • Relevant examination findings
    • Evidence of neurological damage
      • Wasting, fasciculation, reflex changes, hypersensitivity
  • Investigations
    • Relevant imaging

Additional referral information (useful for processing the referral)

  • Preferably patient to complete entry patient questionnaire prior to first consultation
  • Investigations related to co-morbidities e.g. diabetic control

Out of catchment

Metro North Health is responsible for providing public health services to the people who reside within its boundaries. Special consideration is made for patients requiring tertiary care or services that are not provided by their local Hospital and Health Service. If your patient lives outside the Metro North Health area and you wish to refer them to one of our services, inclusion of information regarding their particular medical and social factors will assist with the triaging of your referral.

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can’t order, or the patient can’t afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
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